Multiple Patients on a Ventilator: FAIL

Sometimes medicine behaves like the stock market; a whole bunch of enthusiasm followed by a realistic pullback. This has now occurred with the concept of using one ventilator for multiple patients. I agree that we need to use some ingenuity in this crisis, but this one never sat well with me, hence me not commenting on it at all until now. Too many nuances go into oxygenating and ventilating patients with ARDS. I understand trying this to hold down the fort in a severe crunch, and I tip my hat to those who created the articles and YouTube videos. I'm not trying to be a contrarian or a Debbie Downer.

This statement was put out by the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (ASPF), American Association of Critical-Care Nurses (AACN), and American College of Chest Physicians (CHEST).

Amongst things mentioned here, all patients would need to be paralyzed for this to maybe work. What happens after the 48 hours of paralytics runs it course and they can't play nice on the vent anymore? One always needs an exit strategy. This is something I always teach when taking care of patients in the ICU. I digress, the list provided shows some other safety reasons.

We need to continue thinking outside the box, though, to save all the lives we can. I have never seen our community come together so well. We have done a great job supporting each other. Many have said it already and I agree with them, many of us are going to come out of this psychologically altered. Many of us are, what some would call, jaded in things of life and death. It's part of our daily lives in Critical Care. But this is taking that to another extreme. I appreciate the support that I have received from the community as well. Hope to keep providing you all with great content.

-EJ



Link to ASA Position Statement

Link to SCCM Position Statement

Link to PDF

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Airway pressure release ventilation

We are already seeing severe ARDS from these patients infected with COVID-19. There's discussion out there regarding VV-ECMO, proning, and numerous other strategies to help oxygenate and ventilate our patients. There are numerous different modes on the ventilator to help us achieve these goals but I have found none to be more polarizing than airway pressure release ventilation which is also called APRV. On the Servo vents this is called BiVent (just adding to the confusion of terminology).

Since we are in the process of contemplating providing our patients with anti-retrovirals and anti-malarial drugs, I feel that some of us should reach out of our comfort zone and familiarize ourselves with APRV. If I'm being completely honest, I haven't needed this mode of ventilation much since fellowship. I haven't had many patients in whom I have had such a hard time oxygenating them where I have to reach for this mode. I tend to paralyze patients which is definitely NOT recommended in patients with APRV therefore ameliorating the benefit. I am aware of the PETAL study (Early Neuromuscular Blockage in the ARDS, NEJM 5/2019) which did not show a benefit to paralytics, by the way. My experience is therefore limited, thankfully for my patients who haven't needed me to venture down this road.

The data for APRV is not the most robust, but this recently published review this month contains some great tables and recommendations including the indications and contraindications for APRV, how to set up the vent to initiate APRV, how to troubleshoot the vent depending on the different physiological derangements (I find hypercapnia to be the most common of these personally), and lastly how to wean the vent. I feel the authors did a great job and definitely a good resource to have in your article collection. Stay safe everyone!

A hat tip to the authors.

-EJ

Link to Abstract

Link to FULL FREE ARTICLE

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Prone Positioning for ARDS

I am a huge fan of proning patients who are in ARDS. At one point or another I'll cover the data behind proning like the PROSEVA trial (no time today or until at least June). There are a variety of ways to prone patients which reflect the disposable income of the facilities where you work and train. At the 3 institutions were I have worked and the others where I have done moonlighting shifts, we've all used some good ol' fashioned muscles and coordination.

The PDF quoted and linked here was published in December 2019 and is usually very key during flu season. I am not going to comment about the coronavirus but these patients are developing an ARDS-like syndrome where proning may work. I haven't seen any data, though. That being said, having the ability to prone patients and do it well could potentially save lives.

In the paper, they cover pretty much everything I would want them to in a document like this that's beneficial to all. They even discuss chest compressions and defibrillation in these patients, something we all fear.

The PDF is completely free and a direct link. I need to find out the citation for this bad boy. The authors did a great job and a big hat tip to them. There's a really nice safety checklist and nursing checklist included. 

How do you all prone at your institution?

Do you not prone at your shop because of fear of the tube coming out?

Have you ever had to perform CPR on a proned patient?




Link to FULL FREE GUIDELINES


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Spontaneous Breathing Trials: How Does Your Shop Handle This?

There has been quite a bit of variation regarding pressure support trials, spontaneous breathing trials, liberation trials, whatever you want to call it.
I recently looked at the data for my academic curiosity and would like your input as to how you do it at your shop. I’d like to apologize in advance if I don’t write back to each of you in a timely fashion. I’ll try my best.

Here’s how I like to approach it (in the ideal world).
1. Patient isn’t deteriorating and they’ve done well on their spontaneous awakening trial (SAT).
2. RT goes ahead and places them on pressure support (PS or PSV are the lingo)
3. PS for 30 minutes and the RT flips them back into their prior setting on the vent if they don’t fly.
4. If they do fly, I eyeball the patient and have my RT teammate pull the tube.

I usually have HFNC or NIPPV at the bedside in case they have a high likelihood of needing reintubation.

I know many clinicians check ABGs prior to extubating their patients. I very rarely do. I think I’ve checked maybe 2 or 3 prior to extubating in the almost 2.5 years that I’ve been out of training.

A 🎩 tip to the authors.

Let’s reduce the mechanical ventilation days with this! 💪🏼




Link to Abstract

Link to FULL FREE Article

Ouellette DR, Patel S, Girard TD, Morris PE, Schmidt GA, Truwit JD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest. 2017;151:166–180.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Delirium in Mechanically Ventilated Patients: Let the Natural Light in!

I have great disdain for delirium. Natural light brings me great joy. Today, for example, the sun isn't shining bright. The day is cloudy and gloomy. I am, in turn, a little grouchy. Daylight savings is coming and I'm already upset about it. I can turn on the light but it won't be the same. This study was published today. How's that for so fresh and so clean?

Preventing and treating delirium is something we haven't quite figured out just yet. But studies like this one help us chip away at that giant piece of rock to eventually present a great sculpture. Bad analogy? Yep! In this study, the authors were curious to see whether patients having natural light would affect the incidence of delirium in patients who are on the ventilator (primary outcome). The secondary outcomes included the "duration of delirium, duration of coma, use of antipsychotics to treat agitation, the incidence of hallucinations, the incidence of self-extubation, duration of mechanical ventilation, ICU and hospital length of stay, ICU and hospital mortality."

This was a single centered trial with 195 patients. Out of their measured outcomes, they noted that the patients exposed to natural light had a reduced incidence of severe agitation (p=0.04). In addition, the patients exposed to natural light also had fewer hallucinations (p=0.04). Fortunately, this study is free and you can download it and read it yourself. I like natural light. It's free. It may not ameliorate delirium, but it is another tool in our tool belt to make these patients better.
-EJ

Link to Abstract

Link to full free PDF

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.